Provider Demographics
NPI:1114081205
Name:PHOMVANSI GAMEZ, SIRIVANH (PT)
Entity Type:Individual
Prefix:
First Name:SIRIVANH
Middle Name:
Last Name:PHOMVANSI GAMEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2096 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-5620
Mailing Address - Country:US
Mailing Address - Phone:815-395-8353
Mailing Address - Fax:
Practice Address - Street 1:1340 CHARLES ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2200
Practice Address - Country:US
Practice Address - Phone:815-399-1975
Practice Address - Fax:815-399-3207
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-015351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist